Culley v. Liberty Life- US Ct. of Appeals for the 3rd Cir. gets it right

By Bonny Rafel

In this New Jersey disability claim based on a back condition including disc herniations, the Court affirmed the District Court’s opinion and outlines some important pointers to keep in mind when proving in an ERISA case that the insurer’s procedural irregularities require the denial to be overturned.
The Court faulted Liberty who was acting under a conflict of interest {pursuant to Glenn v. MetLife} for its “decisions that disfavored the employee at each crossroads and reliance on experts who merely reviewed incomplete medical records.”

Interestingly the peer reviewer suggested that Liberty undertake surveillance of its insured to check her functionality,which Liberty declined to do, noting “surveillance is an aggressive tactic” that itself may constitute procedural irregularity.” How can Liberty then, in other cases rush to surveil our clients who have confirmed, significant medical problems which cause functional limitations and restrictions?

Liberty used a Nurse Case Manager to review the appeal, who acknowledged an inconsistency in the views of their hired medical reviewer and the treating physician but then failed to pursue further medical consult to clarify which view to accept. The court reasoned that Liberty cannot turn a “blind eye” to faults in the evidence supporting its consultant’s opinions and then use that opinion to support a denial.